“Infection control is not a new discovery,” Dr Miller said during her talk in Cape Town. “It's been around but it’s always something that we put on the back burner.”
Indeed, the WHO first put out guidelines for TB IC in resource-limited settings in 1999, which have been updated with an addendum related to TB IC in HIV care settings —but these have been poorly implemented. The key activities recommended in WHO and CDC technical guidance are summarised below (see the guidelines themselves in the Resources section).
Five steps to infection control in HIV care settings for preventing TB transmission
From the TB IC in HIV Settings Addendum (this guidance is primarily for outpatient facilities such as ART clinics) (see resources)
Step I: Screen for TB — early recognition of cases or suspects is essential
This can be achieved by assigning a staff member to screen patients for prolonged duration of cough immediately after they arrive at the facility.
Step II: Teach cough hygiene
Clients who screen positive as TB suspects should be instructed to cover their mouth and nose when they cough or sneeze, and handed tissues or handkerchiefs if possible. Face-masks may be an option in some situations.
Step III: Separate
TB cases or suspects by the screening questions must be separated from other patients and requested to wait in a separate well-ventilated waiting area.
Step IV: Provide HIV/AIDS services
Triage symptomatic patients to the front of the line for the services they are seeking
Step V: Investigate for TB or refer
TB diagnosis on site or prompt (and effective) referral — followed by prompt treatment
Good work practice and administrative measures (has the greatest impact)
Environmental measures
- Ventilation (natural and mechanical)
- Filtration
- UV radiation
Personal respiratory protection
- Facemasks may prevent the spread of TB from the patient but teaching cough etiquette is less stigmatising
- N 95 respirators may protect health workers and patients but are expensive (generally only recommended for when other protections aren’t sufficient — such as when seeing someone with drug-resistant TB).
Some have complained that the guidance is too technical or not well-suited to resource-limited countries. But with a little effort, some programmes have been able to adapt the policy to local conditions.
“In establishing national infection prevention control guidelines for TB in South Africa, it has become evident that most of these were derived from existing guidelines in developed countries. Though the principles were sound, the practices were not realistic for developing economies and generally not implemented in healthcare facilities,” said Professor Shaheen Mehtar of Stellenbosch University and Tygerberg Hospital, near Cape Town, in a recent Lowbury Lecture. But Prof Mehtar and colleagues at Tygerberg Hospital took up the challenge and adapted the guidance as best as they could to their setting.
Updated WHO guidelines are in development that should include a package of action steps to help countries start improving TB IC taking into account differences in resources and settings. “We are developing straightforward guidance on what to do at national level in terms of TB infection control in health care and congregate settings and how to prioritise interventions,” WHO’s Dr Fabio Scano told HATIP.
But waiting for new WHO guidelines should not become the next excuse to do nothing. Countries or HIV programmes need to move ahead and adapt the existing guidance and develop tools, information education and communication materials and training packages. At the Three I’s meeting, WHO, the CDC and other technical partners committed to providing technical assistance to help countries “translate” existing guidance into national policy and operating plans (to be discussed at more length in a future report on the Three I’s meeting).
In addition, some helpful tools have already been developed such as those from The Integrated Management of Adolescent and Adult Illness (IMAI) (see resources). Others are being put together by MSF in Khayelitsha working with WHO (contact msfb-khayelitsha-ic@msf.org.za) and PEPFAR is working with ICAP to develop tools based on its experiences in the Eastern Cape.